Coroners’ court reform urged

THE present system of coroners in England and Wales needs to be radically reformed, the Shipman Inquiry said yesterday.

A “complete break with the past” was needed so the coronial system can detect cases of homicide, medical error and neglect, said Judge Janet Smith in the inquiry’s third report.

The third report looked into the issue of death certification and the investigation of deaths by coroners.

In her recommendations, Judge Smith said: “The coronial system should be retained, but in a form entirely different from at present.

“There must be radical reform and a complete break from the past, as to organisation, philosophy, sense of purpose and mode of operation.”

Judge Smith concluded that there was “virtually no training for coroners”.

Many, especially part-time coroners, operate in isolation with little contact with colleagues, which creates a “considerable variability of practice and standards in different coroner’s districts,” she said.

The report said that Shipman, through the issuing of death certificates stating natural causes, was able to evade the coronial system altogether.

“A way must be found to ensure that all deaths receive a degree of scrutiny and investigation appropriate to their facts and circumstances,” Judge Smith said.

“The coroner or member of the coroner’s staff takes what the doctor says completely on trust. In general, no attempt will be made to verify the accuracy of the information given by the doctor from any other source.

“Information provided by the person reporting the death should be cross-checked with a member of the deceased’s family or some other person with recent knowledge of the deceased. If appropriate, other inquiries should be made.”

Judge Smith said a new position needed to be established to investigate non-suspicious deaths.

Coroners officers should also have the support of a team of investigators, who should be specially trained, the report said.